It is four months since the Realising the Value programme published its discussion paper on value in health and care.

We have been digesting the responses, along with other evidence and lessons learned about valuing the contributions of people and communities to care.

Keep an eye on the Realising the Value site for key publications from the programme’s work so far.

In the meantime, we thought it worth sharing some interesting reflections that people have given to us.

Primary care

Great encouragement came from the National Association for Primary Care. NAPC is exploring how to remodel primary care through its Primary Care Home model, which can be integrated with NHS England’s new models of care. It aims for person-centred and coordinated care.

NAPC foresees “holding all providers to account for a small number of shared outcomes [which] would be important and support collaboration and joined up working”.

NAPC wants providers “to unite around responding to what matters to people and communities AND deliver their outcomes – move towards ‘well-being’ and away from ‘ill-being’”.

Local areas should be able to use outcome frameworks focusing on:

• measures that encourage ‘more than medicine’ interventions and demedicalised care
• measures of behaviour change amongst front line clinicians and people, families;  towards 'what I can do for myself?'
• measures of “being in control” of health issues
• wellbeing outcomes for front line teams and people, families.

Broad picture versus personal focus

Our discussion paper wrestled with the twin, but conflicting, needs for generalised and personalised outcomes.

Hospice and neurological charity Sue Ryder notes the tension between trying to arrive at a wide scale, abstract articulation of value, and delivering something that is ‘wieldy and accessible’ for personal use. It suggests deeper and wider discussions with stakeholders would be necessary to manage this conversation as we progress.

Housing innovation agency HACT advises that “if the approach is too particular, the ability to compare outcomes across different services is lost, reducing the opportunity for learning”. It preferred an approach in which a range of tested outcome metrics is produced, and then local stakeholders select from these for their specific projects.

The ELC Programme (which supports the commissioning of experience-led care) suggests the tensions can be managed differently if qualitative data is put on an equal footing with quantitative data as ‘business intelligence’. Rejecting our paper’s view that locally personalised outcomes may not be comparable, ELC says its experience is that people’s value statements can be ‘benchmarked’:

“We believe that the things that matter to most people are actually very similar across health economies…benchmarking will absolutely be possible when we think differently.”

Thinking differently means recognising that both types of data are necessary “to reveal and make sense of previously misunderstood improvement challenges”.

What did we miss?

While responses were generally positive and supportive, there were also criticisms of things we had missed out of consideration.

Public health expert Professor Chris Drinkwater, Chair of Ways to Wellness, strongly argues that by focusing too much on ‘people with established conditions’ we had failed to place value on prevention and on addressing inequalities. Questioning our focus on ‘legitimising’ public value approaches with politicians and the public he reasonably asks: “Do the public and politicians value prevention?” Chris also felt the paper leans too much towards personal rather than community outcomes, whereas “the context in which people live their lives is an important determinant of individual outcomes.”

The ELC Programme identifies another under-represented issue: the increasing extent to which people must self-fund their social care support. This and the increasing use of personal budgets means people are commissioning their own care, and therefore need help both to think about what they want from their life and how they can provide insights about quality and outcomes.

ELC also points out that staff wellbeing is inextricably linked to the quality of support and outcomes for people and should be part of any framework of value.

Finally, although respondents felt we gave a good airing to the way social care outcomes have evolved, they felt we underestimated the effects that cuts to social care funding will have on any attempt to harmonise outcomes across care systems.

Suggested frameworks

The discussion paper asked respondents for their experience of using various alternative values frameworks. We will mention their suggestions here without endorsing any particular one.

• HACT claims to have built “the largest set of methodologically consistent 'social values' in the world, using an approach called wellbeing valuation. By looking at large national datasets, the effect of outcomes like ’smoking cessation' on life satisfaction can be isolated. Academic literature on life satisfaction suggests a strong positive correlation with income, which allows outcomes to be monetised. This means that both costs and benefits can be reported using the same metric (money).”
• ELC Programme has also worked on a new framework, the ELC Life Improver Score: “A PCOM [person centred outcomes measure] that seeks to understand how the person’s life is changing by aggregating their goals around different touch points or domains in their life.”
• The Social Audit Network advocates social auditing as a method that improves on, for example, social return on investment, because it can be built into an organisations’ routine accounting alongside financial values and “allows the robustness of wellbeing reporting to be independently verified”.

So what’s next?

Our discussion paper was a first attempt to open up dialogues on articulating and capturing value in health and care.

Since its publication, Realising the Value has carried out a scoping review of the existing evidence base with a particular focus on the potential benefits of adopting person- and community-centred approaches. This will be published shortly as part of a wider report which brings together in one place a wide range of person- and community-centred approaches for health and wellbeing. The programme has also chosen five local sites as partners whose frontline experience will add further evidence to this knowledge base over the coming months.

We will continue developing a new articulation of value throughout the duration of the programme. We hope you will take the time to engage with us and send us any thoughts or examples that can help move this agenda forwards.

Tell us what you think

If you haven’t responded to the discussion paper, there’s still time to get involved. We’re asking people to consider the following questions:

• What are the elements of value in health and social care?
• Do we understand what it is that people most value?
• And do we have adequate ways to describe the value that people and communities create through their contributions to building and managing wellbeing?

To feed back on the ideas contained in the paper, please contact the consortium partners on [email protected].